A modified tubularised incised plate urethroplasty technique and a revised hypospadias algorithm

Modified snodgrass hypospadias repair using the lembert suturing technique

Background:

Surgical repair of hypospadias deformity is a challenging and complex issue. However, the technique of Snodgrass and its modifications attend promising functional and cosmetic results.

Purpose:

To assess the Lembert suturing technique effectiveness as a modification of the Snodgrass technique in lowering an urethrocutanous fistula rate.

Patients and Methods:

Fifty boys with mid-shaft and distal hypospadias were repaired using the modified Snodgrass technique utilizing the interrupted Lembert suturing technique in neourethroplasty. Patients with previous failed operations or severe chordee were excluded from the study.

Results:

None of the patients develops UCF apart from one who developed complete wound dehiscence following severe wound infection. Mild meatal stenosis is seen in two patients, and one patient experienced a small area of superficial skin sloughing.

Urethral plate in tubularized incised plate urethroplasty: how wide is enough?

Background

Previous reports found that a preincision urethral plate (UP) width <8 mm increased the occurrence of urethroplasty complications (UCs) in tubularized incised plate (TIP) hypospadias repair. However, is the classification of the UP width based on an 8 mm cut-off value to predict the outcome of TIP urethroplasty objective enough or universally applicable? The purpose of our study was to assess the effect of the UP width on the outcomes of TIP hypospadias repair in the Eastern population we served.

Methods

We retrospectively reviewed the records of patients who underwent TIP hypospadias repair by the same surgeon between August 2013 and December 2019 in our hospital. Data were collected, including demographics, intrinsic parameters of the penis, surgical parameters and subsequent surgical outcomes. The data were analyzed and the cut-off value of the UP width was calculated using a receiving-operator curve.

Results

Primary TIP urethroplasty was carried out in 116 patients with a mean age of 35.89±29.40 months. The meatal location was distal in 49 patients, midshaft in 56 patients and proximal in 11 patients. The mean glans width was 12.28±1.36 mm, the mean UP width was 5.74±1.37 mm, the mean neourethral length was 1.96±1.32 cm, and the mean operation duration was 87.52±11.47 min. During a median follow-up of 42 (range: 6 to 80) months, UCs developed in 12 patients, and the UP width was significantly related to the occurrence of UCs (P=0.014). According to the 6 mm cut-off value of the UP width by the receiver operating characteristic curve, patients were divided into two groups. Group A (UP width ≥6 mm) included 69 patients, and Group B (UP width <6 mm), 47 patients. UCs occurred in 3 patients in Group A vs. 9 patients in Group B, P=0.010.

Conclusions

UP width is a potential risk factor for UCs after TIP hypospadias repair. Using this technique with an UP width ≥6 mm is sufficient to result in a good outcome of hypospadias repair.

Assessment of the effect of urethral plate width on outcome of hypospadias repair

BACKGROUND

The paradigm for hypospadias repair is a straight penis with a vertical meatus at the tip of the glans that provides satisfactory urination and is cosmetically acceptable to the parents of the patient.

OBJECTIVE

To determine the cosmetic and functional outcomes of hypospadias repair in relation to the width of the urethral plate.

PATIENTS AND METHODS

This study was a prospective evaluation of patients operated for hypospadias. The urethral plate width (UPW) of the patients were measured preoperatively using vernier calipers. The patients were categorized into groups A and B. Group A patients have a UPW <8 mm, whereas group B patients have a UPW ≥8 mm. The width of the urethral plate was correlated to the cosmetic outcome (using hypospadias objective penile evaluation [HOPE]) and functional outcome (using the urinary stream) of hypospadias repair.

RESULTS

Overall, 47 patients had their hypospadias repaired during the study period. But, only 42 patients who had their distal hypospadias repaired using tubularized incised plate urethroplasty were evaluated. There were 20 patients (47.6%) in group A and 22 patients (52.4%) in group B, with a mean urethral plate of 7.3 mm ± 0.50 SD. The mean UPW in group A was 5.6 mm ± 1.22 SD and the mean UPW in group B was 8.8 mm ± 0.88 SD. Overall, mean HOPE score was 40.0 ± 6.83 SD. Group A patients had a mean HOPE score of 38.7 ± 7.49 SD, whereas Group B patients had a mean HOPE score of 41.2 ± 6.08 SD. P-value was 0.725, which is not statistically significant. Relating good urinary stream (15 in group A and 20 in group B) with the width of the urethral plate statistically (using Spearman correlation technique) gave a P-value of 0.03 (P < 0.05), which is statistically significant.

CONCLUSION

Our findings indicate that the cosmetic outcome of hypospadias repair may not be determined by UPW, but the functional outcome may be predicted by the width of the urethral plate.

URETHROCUTANEOUS FISTULA FOLLOWING SNODGRASS VERSUS TWO STAGE AIVAR BRACKA REPAIR OF DISTAL PENILE HYPOSPADIAS IN MALE CHILDREN: A RANDOMIZED CONTROL TRIAL

Background: Hypospadias is the most common congenital malformation of the urethra with the prevalence of 1 in 200-300 live male births. The objective of this trial was to compare the frequency of urethrocutaneous fistula between Snodgrass and two staged Aivar Bracka repair of distal penile hypospadias in male children. Material & Methods: This RCT was conducted in Department of Plastic & Reconstructive Surgery, Hayatabad Medical Complex, Peshawar, Pakistan from 1st June 2013 to 31st May 2014. 64 male patients were randomly allocated to two surgical procedures, 32 to experimental (Snodgrass) group and 32 to control (two stage Aivar Bracka) group. Age in years, age groups and presence of urethrocutaneous fistula were variables. Age in years was analyzed by mean, SD and range and other variables by count and percentage. McNemar chi-square test was applied to see the significance of difference between the experimental and control groups in terms of frequency of urethrocutaneous fistula at alpha 0.05. Results: Mean age in experimental (Snodgross) group was 6.74 years±1.26 & in control (Aivar Bracka) group 6.71 years ±1.29. The urethrocutaneous fistula was present in three (9.38%, 80% CI 2.77-15.99%) cases in experimental (Snodgross) group and in six (18.75%, 80% CI 9.91-27.59%) cases in control (Aivar Bracka) group. McNemar chi-square test showed no significant difference between the experimental and control groups in terms of frequency of urethrocutaneous fistula. Conclusion: The results are comparable for Snodgrass repair and two stage Aivar Bracka repair for distal penile hypospadias in male children in terms of frequency of urethrocutaneous fistula in our population.